Post-Traumatic Stress Disorder (PTSD)

Linda's story

Linda was walking home from work one evening when she was mugged by a group of men. It was a violent attack and she was hurt quite badly - during the attack she was terrified and was convinced that she would be killed. Linda didn't feel safe after the attack. She found it hard to sleep and would have nightmares about the attack. She would also often be reminded of the worst moments during the day. When she had a memory of the attack she would feel the same sensations of fear and pain she did at the time. Linda went back to work, but she felt scared to go out alone, and panicky around groups of men. She felt that her friends didn't understand how she was feeling, and would get irritable about things that never used to bother her. She felt that she 'shoud be over it', and often thought to herself that she was weak and pathetic.

What is trauma?

Many of us will experience trauma at some point in our lives - an experience which is overwhelming, threatening, scary, or out of our control. Common traumas include:

Being in an accident, such as a road traffic accident

Being the victim of violence, such as being physically or sexually assaulted, imprisoned or tortured

Being in a life-threatening situation, such as a war, a natural disaster, or a health emergency

Witnessing violence towards another person, or witnessing death

Some traumas are isolated 'one off' events which are unexpected and happen out of the blue, other traumas might be expected and anticipated. Some people's jobs make them more likely to experience or witness trauma, such as military or emergency service personnel. Children can experience trauma too, sometimes from the events above, or sometimes at the hands of people who are supposed to be their caregivers. Events which are more likely to lead to PTSD are those which are: experienced as more severe, are interpersonal or deliberate, are unescapable, or are repeated. Trauma that happens earlier in life often leads to more complex outcomes.

What is PTSD?

It is common to be affected by traumatic experiences. Victims of trauma might feel shocked, scared, guily, ashamed, angry, or vulnerable. With time most people get over their experiences without needing professional help. However in a significant proportion of people the effects of trauma can last for much longer. This is called post-traumatic stress disorder (PTSD.

What are the symptoms of PTSD?

Symptoms of PTSD are split into four groups:

Re-experiencing symptoms: Memories of the trauma play over and over in your mind. These memories can come back as 'flashbacks' during the day or as nightmares at night. The memories can be re-experienced in any of your five senses - you might see images of what happened, but also experience sounds, smells, tastes, or body sensations associated with the trauma. Emotions from the trauma can also be re-experienced and it can feel as though the events are happening again.

Upsetting memories of the event intrude into your mind

Having nightmares about the event

Feeling physical reactions in your body when you are reminded of the event

Arousal symptoms: It is common to be 'on edge' or 'on guard' following a trauma. Many people find it very difficult to relax, and find that their sleep is affected.

Always looking out for danger and 'on edge' or easily startled

Difficulty sleeping

Problems concentrating

Avoidance symptoms: A normal human way of dealing with physical or emotional pain is to avoid it, or distract ourselves. People with PTSD often try to avoid any people, places, or other reminders of their trauma. Some people try very hard to distract themselves to avoid thinking about the trauma.

Avoiding reminders of the event

Trying not to talk or think about what happened

Feeling 'numb' or like you have no feelings

Negative thoughts and mood: Trauma can have a powerful effect on how we think. Some people blame themselves for what happened, even when it was not their fault. Others might replay parts of the trauma and think "what if ...?" or "if only ...". Many people with PTSD also experience depression.

Negative thoughts about yourself

Sense of guilt about what happened

Feeling depressed or withdrawn

Does everyone develop PTSD?

After going through a traumatic experience it is common to feel shocked, vulnerable and 'shaken up'. Most people will experience these feelings - they are called an 'acute stress reaction'. With time many people make sense or, or come to terms with, what happened. Things that help people come to terms with trauma include having family and friends around who can support them. In a significant proportion of trauma survivors the symptoms persist – it is as though something got stuck and the experience could not be processed. If symptoms persist then the person is said to have PTSD. Things that make PTSD more likely include greater severity of trauma, greater number of times a trauma happened, and not having as much social support. Some studies with refugees have shown that, unfortunately, given enough traumatic events everyone will experience PTSD.

What keeps PTSD going?

In PTSD memories of traumatic events keep coming back to bother us because they are 'unprocessed'. The event was so overwhelming that the brain was unable to store the memories properly at the time. They keep reappearing in the form of flashbacks and nightmares because they have not had a chance to be stored properly in long term memory. Constantly re-experiencing memories of the trauma keeps us feeling unsafe.

What we think also matters in PTSD. For example, Tim was in a car crash in which his wife died. At the time of the crash he thought he would die, and whenever he remembered the crash he would think he was in danger again. PTSD can shatter (or confirm) beliefs. Before the crash Tim held the beliefs "the world is fair" and "good things happen to good people". After the crash Tim's old beliefs were shattered and he came to believe "I'm in danger" and "there is no point in living". These thoughts left him feeling very vulnerable and depressed.

The way we try to cope with symptoms can have unintended consequences. If we experience unpleasant memories (or any unwanted sensation) it is natural to try to push it away or avoid it. Unfortunately, in PTSD this can mean that the unprocessed memories stay 'stuck'. Trying too hard to avoid parts of life can mean that we live a restricted existence which can have a dramatic effect on how we feel.

The diagram below shows how cognitive behavioral therapists often think about PTSD.

How can I overcome my PTSD?

Professional treatment for PTSD often happens in stages:

The first stage is about 'stabilisation' - feeling 'safe enough'. This stage can include learning about PTSD, and learning grounding techniques to cope with the symptoms. This is something that you can begin to do on your own.

The second stage is about making sense of what happened to you. This can involve talking about what happened and understanding how the events affected you. Evidence-based treatments at this stage include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR)

The third stage is about reclaiming your life. PTSD often makes us live a shadow of our former lives. Once the major symptoms of PTSD are resolved we need to claim back the lives that we want to lead.

1. Stabilization and grounding techniques

One of the common symptoms of PTSD is having memories of the trauma, feeling like the trauma is happening again, or becoming upset when you are reminded of the trauma. This can feel very overwhelming, and exhausting. First, it is helpful to learn about what PTSD so that you don't feel like you're going mad - there are actually very good reasons for the symptoms people with PTSD experience, and it is not your fault! Second it is helpful to begin practising techniques to manage the memories, and the distressing feelings that come along with them.

Read through the instructions on the grounding techniques worksheet, and try putting them into action. You may find some exercises more helpful than others, but persist with each for a while. The aim is not to stop the memories entirely (that often requires specific 'memory processing' work in therapy), but to cope with them when they do occur.

2. Psychological therapy for PTSD

There are a number of very good treatments for PTSD which are supported by research evidence. These include trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR).

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